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Accuracy and Reproducibility of Precordial Percussion and Palpation for Detecting Increased Left Ventricular End-Diastolic Volume and Mass A Comparison of Physical Findings and Ultrafast Computed Tomography of the Heart

Paul S. Heckerling, MD; Stanley L. Wiener, MD; Christopher J. Wolfkiel, PhD; Mark S. Kushner, MD; Emad M. Dodin, MD; Vladimir Jelnin, MD; Benjamin Fusman, MD; Eva V. Chomka, MD
JAMA. 1993;270(16):1943-1948. doi:10.1001/jama.1993.03510160061030.
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Objective.  —To assess the accuracy and reproducibility of indirect definitive precordial percussion in detecting increased left ventricular end-diastolic volume (LVEDV), left ventricular mass (LVM), and left ventricular end-diastolic wall thickness (LVEDWT), and to compare it with palpation of the apical impulse.

Design.  —Descriptive study.

Setting.  —Hospitals and clinics of a university medical center.

Patients.  —Convenience sample of 103 patients (62 men and 41 women) referred for ultrafast computed tomography (CT) of the heart.

Interventions.  —Percussion dullness distance from the midsternal line in the left fourth through sixth intercostal spaces, distance of the apical impulse from the midsternal line, and apical impulse diameter in the left lateral decubitus position were measured on all patients. Measurements of LVEDV, LVM, and LVEDWT were taken using ultrafast CT of the heart. Investigators performing the physical diagnostic maneuvers were blinded to the clinical history and CT results, and investigators performing the CT scans were blinded to physical findings.

Results.  —Percussion dullness distance in the left fifth intercostal space was the best discriminator of LVEDV (receiver operating characteristic [ROC] area, 0.680; 95% confidence interval [Cl], 0.547 to 0.813), and dullness distance in the left sixth intercostal space was the best discriminator of LVM and LVEDWT (ROC areas, 0.831, 95% Cl, 0.674 to 0.988; and 0.849, 95% Cl, 0.651 to 0.999, respectively). A percussion dullness distance of greater than 10.5 cm in the left fifth intercostal space detected increased LVEDV or LVM with a sensitivity of 91.3% (95% Cl, 70.5% to 98.5%) and a specificity of 30.3% (95% Cl, 19.9% to 43.0%). There was moderate concordance between investigators for percussion dullness distance (κ, 0.57; 95% Cl, 0.18 to 0.96). In patients in whom an impulse was palpated, an apical impulse diameter of greater than 3.0 cm in the left lateral decubitus detected increased LVEDV or LVM with a sensitivity of 100% (95% Cl, 77.1% to 100%) and a specificity of 40% (95% Cl, 23.2% to 59.3%). However, an impulse was palpable in only 53% of cases and showed only slight interobserver reproducibility (κ, 0.18; 95% Cl, 0.0 to 0.58).

Conclusion.  —Indirect definitive percussion of the precordium is a sensitive and moderately reproducible maneuver for excluding cardiomegaly due to increased LVEDV or LVM. Although measurement of apical impulse diameter was also sensitive in excluding cardiomegaly, lack of a palpable impulse in many patients and low precision between physicians may limit its utility in clinical practice.(JAMA. 1993;270:1943-1948)


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